Overview
The complainant (Mrs C) was unhappy with the care provided to her late father (Mr A) by Greater Glasgow and Clyde NHS Board (the Board). Mr A was admitted to the Western Infirmary (Hospital 1) on 5 January 2008, as he had been diagnosed with bladder and prostate cancer and his condition was deteriorating. On the following day, it was recorded that he had two pressure sores and that his heel was red and soft. Mr A was transferred to ward 3A in Gartnavel General Hospital (Hospital 2) on 7 January 2008. He was then transferred to the Beatson West of Scotland Cancer Centre (Hospital 3) on 15 January 2008 and discharged on 24 January 2008. During this time, he contracted Noro virus (more commonly known as winter vomiting virus). On 28 January 2008, he was readmitted to Hospital 1 and was transferred to Hospital 2 on the following day. He was discharged again on 5 February 2008. He was then readmitted to Hospital 1 on 9 February 2008, but was transferred to Hospital 2 on the following day. Tests completed showed that Mr A had contracted MRSA and Clostridium difficile. Mr A was referred to the palliative care team on 20 February 2008. Sadly, he died later that day.
Specific complaints and conclusions
The complaints which have been investigated are that:
- (a) the Board failed to effectively manage Mr A's pressure sores (upheld);
- (b) Mr A contracted MRSA and other infections because the infection control measures were inadequate (not upheld);
- (c) there was a delay in referring Mr A to the palliative care team (upheld); and
- (d) there was a lack of continuity in the nursing care provided to Mr A (upheld).
Redress and recommendations
The Ombudsman recommends that the Board:
- (i) undertake a root cause analysis or similar improvement tool to examine the reason why Mr A received inadequate treatment for his pressure ulcers;
- (ii) ensure that the policies in place reflect current national best practice standards for pressure ulcer assessment, prevention and treatment and that robust systems are in place to review, monitor and report adherence;
- (iii) confirm that the learning from report 200702913, published by the Ombudsman in June 2009, is being transferred across the Board region;
- (iv) ensure that there are steps in place to verify that staff are able to diagnose patients who might benefit from palliative care and then make timely referrals to palliative care teams;
- (v) take immediate steps to implement the Liverpool Care Pathway or similar end of life care planning system;
- (vi) continue to review and monitor the nursing care in Ward 3A in Hospital 2. This should include an examination of the clinical leadership and management; the patient experience; and the quality of care. In undertaking the review, consideration should be given to Improvement Methodology and the implementation of the Scottish Government policy for Senior Charge Nurses - Leading Better Care;
- (vii) ask the Director of Nursing to verify that appropriate education and development is in place to ensure that nursing staff throughout the Board are aware of and adhere to national standards in relation to pressure ulcers, control of infection and end of life care;
- (viii) ensure that systems are in place to review and monitor standards of all aspects of nursing documentation in line with professional standards;
- (ix) ensure that patient transfer policies exist and are used in the best interests of patients, ensuring that communication and continuity of care is paramount; and
- (x) make a full and detailed apology to Mrs C for the failings identified in this report.
The Board have accepted the recommendations and will act on them accordingly.